MAUDE Adverse Event Report: ARROW INTERNATIONAL INC. EPIDURAL CATHETERIZATION SET; ANESTHESIA CONDUCTION KIT

Catalog Number JC-05400-B

Device Problem Fluid/Blood Leak (1250)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 12/03/2019

Event Type  malfunction  

Manufacturer Narrative

Qn#: (b)(4).The device has not been returned for investigation.Teleflex will continue to monitor and trend related events.

Event Description

The report states: we still have issues with the syringes available in these kits.The syringes are leaking and cannot be used on the patient.Risk for the patient.We had 16 different individual incidents where i have the syringes back in my office.For each of these incidents the staff has used spare satellites syringes.No individual consequence reported.

Event Description

The report states: we still have issues with the syringes available in these kits.The syringes are leaking and cannot be used on the patient.Risk for the patient.We had 16 different individual incidents where i have the syringes back in my office.For each of these incidents the staff has used spare satellites syringes.No individual consequence reported.

Manufacturer Narrative

Qn#(b)(4).A device history record review could not be performed as no lot number was provided by the customer.The customer reported the lor syringe leaked.The customer returned one 10ml plastic lor syringe (reference files (b)(4)).The syringe was visually examined.Visual examination of the syringe revealed that the syringe appears typical with no observed defects or anomalies.The returned sample was returned to the supplier (preox) for function testing.According to the supplier, "no leakage found by normal handling, leakage if plunger moved to the side".A design history review was performed for part # kz-05501-002 as a part of this complaint investigation.Per eco-051699 (released 03-dec-2018), supplier (preox) made the following changes: kz-05501-002 luer plastic lor syringe: a.Changed plunger material from profax 535 to profax 531; b.Changed to new plunger tool; c.Changed to new mold for blue stopper; d.Changed molding location for the plunger and the blue stopper as follows.- plunger: from fleimaplastic in germany to gpe, germany.- blue stopper: from et, germany to psilkon, germany.These effective changes did impact product design and material.It should be noted, the returned lor syringe was from the new design.The reported complaint of the lor syringe leaking was confirmed based on the sample received.The returned lor syringe was returned to the supplier (preox) for functional testing where according to the supplier, "no leakage found by normal handling, leakage if plunger moved to the side".A device history record review could not be performed as no lot number was provided by the customer.Based on the functional testing by the supplier, the potential root cause of this issue is supplier related.A scar has been initiated to further investigate this issue.

• Brand Name: EPIDURAL CATHETERIZATION SET
• Type of Device: ANESTHESIA CONDUCTION KIT
• Manufacturer (Section D): ARROW INTERNATIONAL INC.; reading PA
• MDR Report Key: 9469987
• MDR Text Key: 179437612
• Report Number: 3006425876-2019-01047
• Device Sequence Number: 1
• Product Code: CAZ
• Combination Product (y/n): N
• PMA/PMN Number: K103658
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: foreign,health professional
• Type of Report: Initial,Followup
• Report Date: 12/03/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/13/2019
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: JC-05400-B
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/19/2019
• Date Manufacturer Received: 01/21/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1